ACO Program: Quality Reporting Requirements. Jennifer Faerberg Mary Wheatley April 28, 2011
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1 ACO Program: Quality Reporting Requirements Jennifer Faerberg Mary Wheatley April 28, 2011
2 Agenda for Today s Call Overview Quality Reporting Requirements Benchmarks/Thresholds Scoring Model Scoring Methodology Data Collection Performance Measures 2
3 Proposed Rule Overview Released March 31; published in Federal Register on April 7 (76 Fed. Reg ) Comments due June 6 OIG, DOJ/FTC and IRS released companion documents same day (limited waivers and antitrust safety zones ) OIG will accept comments through June 6 DOJ/FTC will accept comments through May 31 IRS will accept comments through May 31 Documents available on AAMC website: 3
4 Proposed Rule Overview (Cont.) ACOs would enter into 3 year agreements as early as January 1, 2012 Applies only to Medicare FFS population, not Medicare Advantage (MA) Participants continue to receive FFS payments through agreement period Must meet cost and quality benchmarks to be eligible for savings Quality scores determine percent of shared savings/losses 4
5 5 Reporting Requirements
6 Quality Reporting Requirements Must report on all quality measures to be eligible for shared savings Initially report on 65 measures (more in future years) 5 care domains Patient/caregiver experience (CG-CAHPS) Care coordination (MU, erx) Patient safety (HACs) Preventive health At-risk population/frail elderly health 6
7 Quality Measures Measures primarily physician focused Align with Physician and Hospital Reporting Programs (PQRS, IQR, erx) and Meaningful Use Data submitted via claims, survey and modified PQRS group practice reporting option (GPRO) tool 7
8 Measuring Performance Initial year reporting only no performance thresholds Years 2 and 3 based on performance Must meet minimum threshold for ALL measures Not all measures in current reporting programs 8
9 9 Benchmarks/Thresholds
10 Benchmarks/Thresholds Each measure has a minimum attainment threshold and performance benchmark Minimum threshold proposed at 30 th percentile CMS will determine benchmarks based on Medicare FFS, Medicare Advantage or ACO performance dependent upon data availability Benchmarks available prior to start of the ACO 10
11 11 Scoring Models/Methodology
12 Scoring Models Performance based (proposed model) Ability to score higher percentage based on performance Minimum threshold (30 th percentile) Minimum threshold Minimum threshold higher (50 th percentile) Full savings if minimum threshold met Fixed quality percentage Hybrid Start with threshold and move to performance 12
13 Measuring Performance Measures will be scored similar to hospital value-based purchasing model Receive points for each measure on sliding scale NO points awarded for performance below minimum threshold (30 th percentile) Measures aggregated by domain Domains weighted equally All measures and domains must meet minimum threshold to be eligible for savings Total performance score determines eligible % of shared savings 13
14 Measure Scoring Source pg
15 Total Points Per Domain Domain # Measures 1-sided model: Max Potential Pts Per Domain Patient/Caregiver Experience Care Coordination 2-sided model: Max Potential Pts Per Domain Patient Safety Preventive Health At-Risk Pop/Frail Elderly Health Total Quality Pts Available Max Potential Shared Savings % of savings generated 60% of savings generated 15
16 Quality Scoring and Shared Savings Calculation Example Total Performance Score Percentage Eligible shared savings Amount eligible for shared savings Eligible savings: 1-sided model = 50% 2-sided model = 60% Examples for 1-sided model* 90 th percentile = 100% * eligible savings (50%) = 50% savings 30 th percentile = 55% * eligible savings (50%) = 27.5% savings 16 * Total score based on all required measures
17 17 Timelines
18 Issues/Concerns Minimum thresholds on measures for eligibility Determination of benchmarks Appropriate scoring model Shared savings threshold needs to be raised to account for difficulty in achieving maximum quality score in years 2 and 3 18
19 19 Data Collection
20 Data Collection Three main mechanisms for data collection Surveys Claims analysis Group Practice Reporting Option (GPRO) Reporting Tool 20
21 GPRO Tool - Background Builds off group reporting option for large group practices: Physician Group Practice (PGP) Demo Physician Quality Reporting System group practice reporting option 1 (PQRS GPRO 1) Report on a sample of patients seen by the practice. CMS determines samples for each set of measures Pre-populates a database using claims information 21
22 GPRO Reporting Tool for ACOs Sample Patients Patients attributed to the ACO: plurality of E/M primary care services by primary care physicians Sample size: 411 consecutive patients per measure set/domain. If sample less than 411, ACO must report on all patients. Tool CMS pre-populates a database with patient demographics and utilization ACO fills out remaining information 22
23 Data Collection by Domain Domain # Measures Primary data collection Patient/Caregiver Experience 7 Survey Care Coordination 16 Claims analysis, GPRO Patient Safety 2 Claims or CDC National Healthcare Safety Network Preventive Health 9 GPRO At-Risk Pop/Frail Elderly Health Diabetes (10 measures) Heart Failure (7) Coronary Artery Disease (6) Hypertension (2) COPD (3) Frail Elderly (3) 31 GPRO and Claims analysis 23
24 Aligning with PQRS ACOs that meet quality requirements can receive PQRS Group incentive payment 0.5% incentive for Applies to all TINs in the ACO CMS does not propose to incorporate other incentive programs (Medicare EHR Reporting or E-Prescribing (erx) Incentive Program) 24
25 25 Measures
26 New Items Ambulatory patient satisfaction surveys New composites New populations/measure sets added to the GPRO reporting tool 26
27 Domain 1: Patient Caregiver Experience Measures (Data collection): Clinician/Group CAHPS (Survey): 1. Getting Timely Care, Appointments, and Information 2. How Well Your Doctors Communicate 3. Helpful, Courteous, Respectful Office Staff 4. Patients' Rating of Doctor 5. Health Promotion and Education 6. Shared Decision Making Medicare Advantage CAHPS (Survey): 7. Health Status/Functional Status 27
28 Domain 2: Care Coordination Measures (Data collection): Transitions 8. Risk-standardized all condition readmission* (claims) Day Post Discharge Physician Visit* (GPRO) 10. Medication Reconciliation (GPRO) 11. Care Transition Measure (GPRO or Survey) 28 * Measure not NQF-endorsed All measures new to pay-for-performance programs
29 Domain 2: Care Coordination (cont.) Measures (Data collection): AHRQ Prevention Quality Indicators* (claims) 12. Diabetes, short-term complications 13. Uncontrolled Diabetes 14. Chronic obstructive pulmonary disease 15. Congestive Heart Failure 16. Dehydration 17. Bacterial pneumonia 18. Urinary infections * The Prevention Quality Indicators (PQIs) are a set of measures that use hospital inpatient discharge data to identify quality of care for "ambulatory care sensitive conditions." 29
30 30 Domain 2: Care Coordination (cont.) Measures (Data collection): Information Systems (GPRO)* 19. % All Physicians Meeting Stage 1 HITECH Meaningful Use Requirements 20. % of PCPs Meeting Stage 1 HITECH Meaningful Use Requirements By start of year 2, ACOs must have at least 50% of PCPs meeting this requirement 21. % of PCPs Using Clinical Decision Support 22. % of PCPs who are Successful Electronic Prescribers Under the erx Incentive Program 23. Patient Registry Use * CMS to validate GPRO attestation through EHR Incentive data and erx Incentive Program
31 Domain 3: Patient Safety 31 Measures (Data collection): 24. Hospital Acquired Condition Composite (claims or CDC) - NEW Foreign Object Retained After Surgery Air Embolism Blood Incompatibility Pressure Ulcer, Stages III and IV Falls and Trauma Catheter-Associated UTI Manifestations of Poor Glycemic Control Central Line Associated Blood Stream Infection (CLABSI) Surgical Site Infection AHRQ Patient Safety Indicator (PSI) 90 Complication/Patient Safety for Selected Indicators (composite) 25. Health Care Acquired Conditions: CLABSI Bundle (claims or CDC)
32 Domain 4: Preventative Health All measures collected through GPRO tool: 26. Influenza Immunization 27. Pneumococcal Vaccination 28. Mammography Screening 29. Colorectal Cancer Screening 30. Cholesterol Management for Patients with Cardiovascular Conditions* 31. Adult Weight Screening and Follow-up* 32. Blood Pressure Measurement 33. Tobacco Use Assessment & Cessation Intervention* 34. Depression Screening** 32 * Measure not in PQRS GPRO, but is in Medicare EHR incentive program ** Measure in PQRS, but not PQRS GPRO
33 Domain 5a: At-Risk Diabetes 33 All measures collected through GPRO tool: 35. Diabetes Composite (All or Nothing Scoring): NEW Hemoglobin A1c Control (<8%) Low Density Lipoprotein (<100) Blood Pressure <140/90 Tobacco Non Use Aspirin Use 36. Hemoglobin A1c Control (<8%)* 37. Low Density Lipoprotein (LDL-C) Control in Diabetes Mellitus 38. Tobacco Non Use* 39. Aspirin Use** * Measure not in PQRS GPRO, but is in Medicare EHR incentive program ** Measure not in PQRS GPRO and measure not NQF-endorsed
34 Domain 5a: At-Risk Diabetes (cont.) All measures collected through GPRO tool: 40. Hemoglobin A1c Poor Control (>9%) 41. High Blood Pressure Control in Diabetes Mellitus 42. Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients 43. Dilated Eye Exam in Diabetic Patients 44. Foot Exam 34
35 Domain 5b: At-Risk Heart Failure All measures collected through GPRO tool: 45. Left Ventricular Function (LVF) Assessment 46. Left Ventricular Function (LVF) Testing 47. Weight Measurement 48. Patient Education 49. Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 50. ACE Inhibitor or ARB Therapy for Left Ventricular Systolic Dysfunction (LVSD) 51. Warfarin Therapy for Patients with Atrial Fibrillation 35
36 Domain 5c: At-Risk CAD All measures collected through GPRO tool: 52. Coronary Artery Disease (CAD) Composite: All or Nothing Scoring NEW Oral Antiplatelet Therapy Prescribed Drug Therapy for Lowering LDL-Cholesterol Beta-Blocker Therapy for Patients with Prior MI LDL Level <100 mg/dl ACE Inhibitor or ARB Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD) 36
37 Domain 5c: At-Risk CAD (cont.) All measures collected through GPRO tool: 53. Oral Antiplatelet Therapy Prescribed for Patients with CAD 54. Drug Therapy for Lowering LDL-Cholesterol 55. Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) 56. LDL level < 100 mg/dl* 57. ACE Inhibitor or ARB Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD) * Measure not in PQRS GPRO and measure not NQF-endorsed 37
38 Domain 5d and 5e: At-Risk Hypertension and COPD All measures collected through GPRO tool: Hypertension 58. Blood Pressure Control 59. Plan of Care Chronic Obstructive Pulmonary Disease (COPD)* 60. Spirometry Evaluation 61. Smoking Cessation Counseling Received** 62. Bronchodilator Therapy based on FEV1 * Population not in PQRS GPRO ** Measure not NQF-endorsed 38
39 Domain 5f: At Risk Frail/Elderly* 63. Falls: Screening for Fall Risk (GPRO) 64. Osteoporosis Management in Women Who had a Fracture (GPRO) 65. Monthly INR for Beneficiaries on Warfarin (Claims) * Population not in PQRS GPRO 39
40 Measures Summary Positives: Align with PQRS GPRO reporting Builds on previous group reporting Framework to measure systems 40
41 Measures Summary Concerns: Total number of measures Double count effect HAC, readmission, meaningful use, e- prescribing all reported twice 50% of PCPs reach meaningful use by year 2 New composite measures New measures not previously included in payfor-performance programs Time needed to complete new GPRO modules 41
42 Upcoming Calls Thursday, May 5, 2:00 p.m. Eastern Legal (in-house counsel only) Thursday, May 12, 2:00 p.m. Eastern Beneficiary Attribution and Payment 42
43 Resources Contact information: Jennifer Faerberg Mary Wheatley 43
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